Cyberinfidelityhelp.com - Authorization of Release of Records

Authorization of Release of Records or Information

Kanaris Psychological Services, P.C.
Name of Patient
Social Security Number
KPS Doctor
I, (name of patient mentioned above), (with a social security number mentioned above), hereby
Give permission to: (doctor mentioned above) performing services on behalf of KPS in connection with my treatment to:
Name of agency, attorney, school counselor, therapist, etc.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Please enter a valid phone number.Format: (000) 000-0000.
Would you like to release your entire record?
Select all information you would like to be released apply

Other
Form in which information should be release:

Other
The purpose of this disclosure is:

Other
I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. If I do not revoke it, this consent will expire one (1) year after I have terminated treatment with all providers affiliated with KPS
Signature of patient
Signature of parent, guardian, conservator or authorized representative (when required)
Date

MonthDayYear
Date
Witness
NOTICE TO RECIPIENT OF INFORMATION

This information has been disclosed to you from records the confidentiality of which may be protected by federal and/or state law. If the records are so protected, Federal Regulation (42 CFR Part 2) prohibits you from making any further disclosure of this information unless disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alochol or drug abuse patient.
Should be Empty:

Authorization of Release of Records or Information